A health education outreach partnership between an academic medical library and public library: lessons learned before and during a pandemic

Background: Public libraries serve as community centers for accessing free, trustworthy health information. As such, they provide an ideal setting to teach the local community about health and health literacy, particularly during public health crises like the COVID-19 pandemic. Since 2018, an outreach partnership between an academic medical library and public library has developed, delivered, and continuously evaluated a health education program targeting public library users. Case Presentation: Health education activities were integrated into three existing public library programs: adult workshops, child and family programming, and circulating family activity kits. Prior to COVID-19, events were held at the public library, which then pivoted online during the pandemic. An interprofessional team approach combined the expertise of academic medical and public librarians, medical school faculty and staff, and medical students in developing the educational programs. Twelve in-person and five virtual programs were offered, and five circulating health education family kits were launched. Activities were assessed using program evaluation surveys of the adult and children's programs and circulation statistics of the kits. Conclusions: This case report showcases the lessons learned from implementing a longitudinal outreach partnership between an academic medical library and public library before and during the COVID-19 pandemic. The interprofessional team approach and flexibility in program design and delivery in both the in-person and virtual environments proved critical to the success of the partnership. This partnership could serve as a model for other libraries interested in pursuing interprofessional collaborations in educating local communities on healthy behavior and health information–seeking practices.

public libraries provide opportunities to share expertise and resources in addressing consumer health information needs, such as medical librarians conducting training for public library staff and offering collaborative health programming [14][15][16][17][18].
This case study reports on the development, implementation, and evaluation of a health education partnership between the Oakland University William Beaumont School of Medicine (OUWB) Medical Library and Auburn Hills Public Library (AHPL). It represents an interprofessional collaboration between academic medical librarians, public librarians, medical school faculty and staff, and medical students to educate the local community on positive health behaviors and health information-seeking practices.

CASE PRESENTATION
Community outreach and engagement are integral to OUWB's mission, vision, and values and are a priority for the medical school and university [19][20][21]. AHPL is located near the university and serves a diverse community including adults over sixty-five, children, and over 5,000 families [22]. In addition, a greater percentage of Auburn Hills residents are uninsured and have higher unemployment rates than Michigan state averages [23]. Integrating health information activities into existing library programs provides an effective means of reaching many members of the community in teaching them how to access, evaluate, and use health information.
The collaboration began in August 2018 when the OUWB Medical Library approached AHPL about their interest in and patron need for health education and health information literacy. Both libraries shared a mutual interest in increasing health programming, promoting healthy behaviors, and raising awareness of free, reliable health information resources. As a pilot, an adult workshop and two children's programs were offered at the public library in fall 2018. Based on feedback from public librarians and attendance, the pilot was deemed successful. This subsequently evolved into a partnership focused on integrating health education into three existing public library programs: adult workshops, child and family programming, and circulating family activity kits, all of which pivoted online during the COVID-19 pandemic. In addition, after the pilot year, the team received a National Network of Libraries of Medicine All of Us Public Library Partnership Award to fund supplies and develop and evaluate additional programs. This funding resulted from a National Institutes of Health/National Library of Medicine partnership to promote the All of Us Research Program and support increasing health literacy activities at public libraries [24]. The Oakland University institutional review board determined this project was non-human subjects research.

Adult workshops
Description AHPL hosts regular weekend workshops targeting adults on a variety of topics, with a special emphasis on developing programming for seniors. The adult services librarian and the medical librarian collaborated to add an expert speaker series on popular health topics; three inperson sessions were delivered at the public library on influenza and hepatitis A, pain management, and fad diets. For each session, the medical librarian invited a medical school faculty member to develop and coteach a workshop on the topic, while the public librarian promoted and hosted the event.
Pre-COVID-19, sessions were one hour and included the expert speaker presentation, a brief demonstration of related online health resources by a medical librarian, a question-and-answer portion, and a post-session evaluation. During the pandemic, sessions pivoted to mini virtual asynchronous offerings. An OUWB faculty member demonstrated mindfulness practices via a twenty-minute "follow-along" recording embedded on the AHPL website. Table 1 reports the total number of attendees and views for each session.

Evaluation
After the pilot, an anonymous survey was developed to evaluate general library programming and that day's workshop [25]. Nine of 12 participants from the two subsequent workshops completed the survey, a response rate of 75%. All respondents (n=9) rated the workshops as good or excellent (n=9). They reported learning about the event through library social media (n=4), on-site library advertising (n=3), or the library website, library newsletter, local newspaper, or word of mouth (n=1, each). Recommendations for future workshop topics included physical activity, Alzheimer's disease, addiction, and cannabidiol.

Children & family programs
Description AHPL offers weekly family story times (for preschoolaged children) and monthly science, technology, engineering, arts, and math (STEAM) programming (for elementary school-aged children). The youth services librarian suggested integrating health education into these two popular existing programs and brainstormed topic ideas with the medical librarian. The medical school librarian, faculty, and staff then partnered with the OUWB Lifestyle Medicine Student Interest Group to develop and deliver the children's programming, with the public librarian managing marketing and hosting the event. From 2018 to 2020, nine in-person children's events were hosted on the following topics: germs and handwashing, jmla.mlanet.org   (Table 1).
Pre-COVID-19, each program featured the youth services librarian reading a book on the health topic followed by hands-on activities led by medical students. Eighty-one children attended these programs over three years while over twenty OUWB student volunteers were engaged. With the onset of the pandemic, these sessions were converted to instructional videos and a take-home activity kit. Instructions directed children to watch an online video in which a medical student read a book on the designated topic and led them through an activity completed with the supplies provided. These were created as single-use kits that families kept. To date, two takehome activities have been created on the digestive tract and the skeletal system with fifty kits distributed to families.
To ensure the community had access to reputable health information during the pandemic, AHPL offered a new, virtual health education program: Ask-a-Doc. During this program, a public librarian interviewed a physician about COVID-19 and gave families the opportunity to ask questions. The medical librarian recruited clinical faculty and the public librarian developed interview questions, advertised, and hosted the event. Two sessions were offered: "Safety and Wellness during COVID-19" and "Mental Wellness during COVID-19." Each session was thirty to sixty minutes long and held virtually via Zoom while live-streamed to the public library's Facebook page. The recordings have over eighty views to date.

Evaluation
In the second year of the partnership, two evaluation tools were implemented to assess these programs: a postsession evaluation survey for child participants and a medical student communication observation tool to evaluate their interactions.
As the ages of the child participants ranged from five to twelve years, the guided survey tool needed to be brief and simple to accommodate all ages. A three-question survey was developed with two questions using an emotion scale of smiley faces as reported by previous studies [26,27] (Figure 1). All but one child participant completed the program survey (n=30) over the three programs offered during the second year. Most children selected "I learned a lot" (n=24), with a majority selecting either the super smiley or smiley face when asked how much fun they had (n=28) and how they liked the medical student teachers (n=28).
In addition, the Teach-back Observation Tool, typically used to observe health provider communication skills with patients, was modified for a health education Figure 1 Children's program evaluation survey setting to provide feedback on medical student teaching performance [25,28]. The tool assesses communication items using a dichotomous scale (yes/no) and a comments section to identify characteristics such as caring tone, welcoming body language, limited use of medical jargon, and asking open-ended questions. At each session, two to three observers (medical school faculty and medical librarians) completed the observation checklist for the medical student facilitators. The collected observation data indicated that students consistently displayed a caring tone and welcoming body language and often asked openended questions. They maintained professionalism while entertaining the children and creating a fun, engaging environment. Areas for improvement were (1) avoiding medical jargon and adjusting language to the appropriate literacy level and (2) making sure learners grasped a topic, particularly when introducing an activity. However, as many students volunteered at several sessions, observers commented on improvements in communication skills over time. Students were able to use skills and techniques learned from their clinical training curriculum, such as engaging patients and distilling complex information, and adjust them to a younger age group. In addition, informal feedback was gathered from medical students during session debriefs, in which they indicated that participating in these activities contributed to their ability to work with diverse populations and ages.

Circulating health kits
In addition to offering educational programs, AHPL creates circulating activity backpacks as part of their children's collection. Each backpack is themed and includes books, an activity sheet, online resource links, and educational toys or games. A medical student, youth services librarian, and medical librarian selected five topics for health-related kits based on the perceived interest of families: germs and handwashing, nutrition, exercise, mindfulness, and medical careers. Five kits were developed and released into circulation in February 2020, but paused due to COVID. Kits began recirculating in July 2021 with thirty-six total checkouts to date (Table 1).

Lessons learned: successes
Previous studies of academic medical and public library partnerships fall into two main approaches: (1) medical librarians training public library staff in health information resources [14,15] and (2) collaborating to plan and offer health programming targeting library patrons [16][17][18]. Many attributes of successful library outreach previously reported in the literature were found in this project, including sharing mutual interests and goals, aligning with institutional missions, and addressing community interests and needs [1,20,29,30]. This project also revealed unique elements that could be adapted by other libraries seeking to implement similar programs. These include utilizing an interprofessional team approach beyond librarianship and implementing flexible delivery methods as needed, in this case by shifting online during COVID-19 to address emerging health concerns of the community.

Interdisciplinary team approach
Collaboration, both within and outside librarianship, proved invaluable to the success of this outreach partnership. Without the interprofessional collaboration between the medical library, public library, and medical school, we would not have been able to successfully develop and deliver as many programs and events. First, the public librarians had a solid knowledge of patron interests and popular circulating item topics to guide the team; this provided the opportunity for directed health topics to be addressed. Also, having an established audience who frequently attended existing library programs allowed us to leverage existing opportunities to introduce the community to these health education activities. Second, the participation of medical school faculty and staff provided the team with additional resources and supplies. Because these medical school faculty and staff had previously developed programming with local public school districts, they also brought expertise in K-12 education and community engagement to the team. Also, there was sharing of a robust set of existing and newly acquired supplies, educational materials, and educational activities that could be modified for specific age groups. Finally, collaborating with leaders from a medical student interest group also allowed for efficient recruitment of engaged volunteers to facilitate events at the public library. Many volunteers also had previous experience working with K-12 students and were able to develop experiential sessions for the children and family programming. See Table 2 for a summary of roles and responsibilities.

Flexible delivery method
Mode of delivery requires a flexible approach and basic understanding of various accessible online delivery platforms. Pre-COVID-19, the partnership was steadily growing with all programs hosted in person at the public library. Children's programs were especially well attended, with evaluation data indicating that the children enjoyed and learned from these sessions. As COVID-19 closed both the university and public library, planned inperson sessions were cancelled. One success was observing and learning from the experiences of the public librarians as they experimented in offering virtual programs through different platforms. Our health education activities resumed by following their lead and integrating into the library's virtual and socially distanced programs. This included developing asynchronous recorded instructional videos and posting them on YouTube, hosting Zoom sessions simultaneously livestreamed to Facebook, and offering take-home kits for families. This approach allowed the health education activities to continue even with the challenges presented by the pandemic.
While integrating in-person events into existing public library programs proved successful in terms of attendance and engagement, pivoting to virtual programs revealed several takeaways for planning education sessions in the post-pandemic future. Virtual sessions were easier to implement without the logistical considerations of volunteer recruitment and training or setup and takedown of physical spaces, which reduced planning and implementation time. Virtual programs also reached a larger audience. For children's activities, fifty families were able to pick up take-home kits, compared to an average of twelve attendees at each in-person session. For adult programs, there was an average of sixty views of live-streamed or asynchronous recorded sessions compared to an average of five participants at adult inperson sessions. This suggests that post-pandemic outreach programming should consider hybrid (live inperson session and accompanying asynchronous recording) or fully virtual options. A hybrid approach where participants can watch at their leisure provides flexibility for interested patrons by accommodating busy schedules. These opportunities mirror those reported in the literature, which anticipate libraries offering a greater number and variety of programs and services in flexible, hybrid formats post-pandemic [8,10,31]. However, a major drawback of fully virtual programs was the lack of personal interactions and experiential learning, including (1) engaging with medical students, physicians, and faculty directly, (2) opportunities to ask questions, and (3) having personalized learning experiences. While hosting educational and interactive events accounted for a large portion of this project, take-home kits proved very

Lessons learned: challenges
Marketing Special consideration should be given to active versus passive marketing approaches when advertising events not integrated into existing programs. Integrating activities into recurring weekly library children's programs yielded the most success along with marketing the children's programs on the library's social media platforms and print flyers. The adult programs were mostly passively marketed: posted on the website events calendar, print flyers, and in a quarterly print newsletter sent months in advance. As a result, attendance at these events was lower than the children's events. Future marketing efforts should include more active approaches such as utilizing social media, reaching out to local senior centers or communities, and planning events closer to mass media coverage, such as the influenza and hepatitis A workshop that was offered too long after a statewide hepatitis A outbreak.

Engaging specific audiences online
Pre-COVID-19, topic selection for adult programs was driven by trends in circulation requests, direct questions from patrons, and current events. Keeping abreast of topics of interest to seniors posed the unique challenge of integrating easy-to-understand online resources while dispelling possible misinformation or myths. During COVID-19 and the subsequent public library closure, the adult services librarian reported that attendance at virtual synchronous adult programs was poor and suggested developing short asynchronous recordings. Mindfulness was selected as the topic of the first recording by the public librarian to help community members manage pandemic-related stress [32]. However, anticipating the health literacy needs and questions of patrons became problematic as the pandemic progressed and the public was flooded with competing and contradictory information from various media and personal sources. In addition, it is unclear if seniors, the target adult audience, felt comfortable with or had adequate digital literacy skills to engage in online programs. However, as a recent Pew Research Center survey found that 25% of Americans aged sixty-five and older do not use the Internet, online programming may unintentionally exclude this age group [33]. As such, post-COVID-19, there may be additional outreach opportunities both online and in person, such as hosting library events directly at senior community centers or housing facilities. In the future, considerations need to be made to ensure that this population is included and if digital literacy may be an opportunity for future education.

Enduring turnover & sustainability
Sustainability is one of the most commonly reported challenges of outreach [1,20,29,30]. As institutional missions evolve, interests change, and staff turnover occurs, outreach projects are often the first to be affected. COVID-19 has also impacted the workforce with many organizations experiencing unprecedented rates of staff turnover due to changing work environments and demands [34]. Partnerships such as the one described here may be particularly vulnerable to such changes [30]. During the course of the partnership, the primary coordinating medical librarian left for another position and other staffing changes in the medical library caused a shift to reprioritize basic library services. However, the strong foundations of this partnership and the interdisciplinary team approach contributed to programmatic resiliency, with champions from the medical school currently working to preserve the partnership with the public library.
Public libraries serve as cornerstones of their communities and are trusted sources of free, reliable information, including health information. The COVID-19 pandemic showcased the increased need and importance of health literacy in driving health care decision-making. Libraries can promote their role in addressing this need by offering programs and building collections. This case report demonstrates the ongoing importance of educational outreach initiatives in addressing the changing health landscape and ongoing health information needs of the community, particularly during COVID-19. Partnerships between medical and public libraries, especially those that leverage the expertise of health care professionals, can create successful interprofessional teams that are flexible, sustainable, and capable of sharing valuable resources, time, and both physical and virtual spaces.

ACKNOWLEDGMENTS
We thank our other valued colleagues at Auburn Hills Public Library, Gina Labban, adult services librarian, and Jessica Jacks, teen services librarian, for their continued collaboration and support in offering these health education programs. We also thank the OUWB COMPASS Center for Community Engagement for their financial support of this project. In addition, this project was supported by the National Network of Libraries of Medicine Greater Midwest Region All of Us Public Library Partnership Award [#1UG4LM012346, 2019].

DATA AVAILABILITY STATEMENT
Data associated with this article are available in the OUR@Oakland institutional repository at <http://hdl.handle.net/10323/11355>. Education materials developed from this project, including PowerPoints, lesson plans, and supply lists, are available from the corresponding author by request.

AUTHOR CONTRIBUTIONS
Stephanie M. Swanberg